Mellex, thanks for sharing your concerns and questions. Likewise, we appreciate all the work Taimaka does to address malnutrition and have appreciated the lessons your team has shared with us on ORS/zinc distribution!
Preventing duplicate enrollment and vaccination is something we think a lot about. In 2024, we tightened our requirements so that the same caregiver must present the child at each visit after the initial visit. We also use caregiver biometrics as a proxy, indexing photos from all disbursements in a 20km radius. We have found the biometric review process to be quite accurate in identifying duplicate individuals. For example, we’ve had to exclude false positives where clinic staff appearing in the background of photos were identified and then linked to program IDs as potential duplicates. Over the past year, we’ve averaged a duplicate enrollment rate below 2%. When a caregiver is identified as a duplicate, they are blocked from receiving future disbursements. We have multiple opportunities to identify a duplicate caregiver throughout the RI schedule, which makes it difficult to bypass the system repeatedly. However, if you do hear of specific cases or clinics where this is happening, please do share that with info@newincentives.org, and we will pass those along to our Audits team to investigate. They will assess trends at nearby clinics and compare them against the duplication rates we are detecting in the area. This type of triangulation really helps us improve the system.
To enroll in the program, children must be under 1 year old. This reflects the period when routine immunization has the greatest impact in preventing childhood disease and mortality. We see that in many states where we work, there are still large numbers of 6 to 12-month-olds not being vaccinated, and thus our work continues to focus on reaching younger children (both at the clinics and through outreaches/campaigns) with the goal of reducing the number who reach age 2 without completing their routine immunization schedule. We are also starting to think about missed opportunities for co-coverage of essential health interventions such as growth monitoring and malnutrition services.
Thanks for these thoughtful questions, and you’re right that scaling hasn’t been straightforward.
The favorable exchange rate has significantly improved our dollar-denominated cost per infant. The Naira has depreciated by roughly 4x relative to the dollar since 2020, which is the dominant driver of that reduction. At the same time, we’ve increased our total cash transfer from N4,000 to N11,000 to keep the incentive meaningful for caregivers in light of inflation. We also track budget-versus-actuals in detail and review operational trends weekly. That visibility has helped us adapt to many of the realities of operating in remote and insecure areas while also identifying cost efficiencies. Managing costs at scale requires continuously responding to changing conditions such as inflation, fuel prices, security dynamics, and transportation constraints.
Expansion to other geographies is an open question. We’ve reviewed different countries, weighing factors like security, existing health infrastructure, disease burden, vaccination coverage, and population density (some top countries include Niger, DRC, Chad, and Cameroon). We may extend our coverage surveys to Niger as a near-term step because we think there may be some important similarities to northern Nigeria and potential gaps in existing vaccination data that could help answer key questions related to estimated cost-effectiveness. We’re also exploring a lower-cost delivery model (see below) that could make expansion more viable in contexts where our current model would not be cost-effective to operate.
We think the most promising path to improving cost-effectiveness is through alternative incentive modalities. We’re actively exploring how to deliver cash incentives through clinic staff or community mobilizers. If we can develop a lower-overhead transfer method that reaches caregivers directly at the point of immunization with appropriate verifications, it could unlock geographies where our current delivery model is not cost-effective enough to operate. We’re interested in understanding what becomes possible when delivery costs fall substantially by challenging assumptions and adapting the model to different operational contexts.